Trigeminal neuralgia (TN) caused by the primitive trigeminal artery (PTA) and PTA variants is ver... more Trigeminal neuralgia (TN) caused by the primitive trigeminal artery (PTA) and PTA variants is very unusual, accounting for 0.2-0.6％ of TN cases, particularly the intermediate PTA type which is extremely rare and has only been reported twice in previous studies. We describe a case of TN caused by an anomalous artery originating directly from the PTA. A 68-year-old woman with a 4-year history of TN in the right V2 distribution visited our hospital. The patient's pain was poorly controlled with oral medicine. The 3D MRI/MRA fusion and MR constructive interference in steady state(CISS)images revealed an abnormal artery branching from the PTA compressing the trigeminal nerve in the cerebellopontine angle. During microvascular decompression (MVD) , the offending artery was transposed at two points on the trigeminal nerve, the root entry zone, and the cisternal portion. The patient's TN improved immediately after surgery. The patient's postoperative course was uneventful. Both, 3T MRI/MRA 3D fusion and CISS images were useful in identifying the anatomical relationship between the PTA and the trigeminal nerve, thus, allowing the optimal operative strategy.
Although microvascular decompression (MVD) is a reliable treatment for trigeminal neuralgia (TN),... more Although microvascular decompression (MVD) is a reliable treatment for trigeminal neuralgia (TN), neurosurgeons sometimes encounter patients whose symptoms do not improve postoperatively or who experience good treatment efficacy but develop other sensory disturbances. This study aims to objectively identify changes in nerve fibers before and after surgery by MRI and to clarify the relationship between the changes and residual postoperative symptoms. We retrospectively analyzed data from 36 consecutive patients who underwent MVD for classical TN at our hospital between November 2019 and November 2020. Cases that fulfilled the diagnostic criteria for multiple sclerosis were excluded. We confirmed the changes on the brainstem side of the trigeminal nerve preoperatively and at seven days postoperatively using 3D T2-SPACE MRI, in which the patients were divided into three groups: preoperative T2 high intensity positive (A), postoperative T2 high intensity positive (B), and no T2 highintensity region (C). The primary outcome measures were therapeutic efficacy and frequency of postoperative numbness. The results of MVD surgery were evaluated one year postoperatively. The percentage of cases in which treatment outcomes were rated as excellent or good at one year: group A: 0 (0%), group B: 6 (100%), and group C: 25 (96.2%) (p < 0.05); the frequency of numbness: 2 (50%) in group A, 3 (50%) in group B, and 1 (3.8%) in group C, indicating significant differences between the three groups (p < 0.05). 3D T2-SPACE MRI sequences can be used to identify changes in trigeminal nerve fibers before and after MVD, which might correlate with eventual residual symptoms.
Neck clipping of large internal carotid-posterior communicating artery (IC-PC) aneurysms is gener... more Neck clipping of large internal carotid-posterior communicating artery (IC-PC) aneurysms is generally difficult, especially when the anterior choroidal artery adheres to the aneurysm. We report 2 cases with premature rupture during the dissection of the anterior choroidal artery adhering to aneurysmal dome. The rupture point was not from the dissecting area, but from the medial wall of the aneurysmal dome, which also adhered to optic nerve. The traction force seemed
Although microvascular decompression (MVD) is a reliable treatment for hemifacial spasm (HFS), po... more Although microvascular decompression (MVD) is a reliable treatment for hemifacial spasm (HFS), postoperative delayed relief of persistent HFS is one of the main issues. In patients with hemifacial spasm, stimulation of a branch of the affected facial nerve elicits an abnormal response in the muscles innervated by another branch. Several specific types of waves were found in the abnormal muscle response (AMR). This study aimed to confirm the relationship between the initial morphology of the AMR wave and delayed relief of persistent HFS after MVD. We retrospectively analyzed and compared the data from 47 of 155 consecutive patients who underwent MVD for HFS at our hospital between January 2015 and March 2020. Based on the pattern of the initial AMR morphology on orbicularis oculi and mentalis muscle stimulation, patients were divided into two groups, namely, the monophasic and polyphasic groups. The results of MVD surgery for HFS were evaluated 1 week, 1 month, and 1 year postoperatively, by evaluating whether or not the symptoms of HFS persisted at the time of each follow-up. There were significantly higher rates of persistent postoperative HFS in patients with the polyphasic type of initial AMR at 1 week and 1 month after the surgery (p < 0.05, respectively), as assessed using Yates chi-squared test and Fisher's exact test. A significant correlation was observed between delayed relief after MVD and polyphasic morphology of the AMR in electromyographic analysis in patients with hemifacial spasm.
The Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study and its pooled analysis showed t... more The Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study and its pooled analysis showed that intensive blood pressure (BP) lowering reduced recurrent stroke risk by 22% in patients with a history of stroke. Here, we report the effect of intensive BP lowering on the risk of recurrent stroke subtypes in patients with a history of ischemic stroke. RESPECT was a randomized clinical trial among 1280 people with a history of cerebral infarction or intracerebral hemorrhage. Participants were assigned to the intensive blood pressure control group (blood pressure < 120/80 mmHg) or standard blood pressure control group (blood pressure < 140/90 mmHg). In this post hoc analysis, we analyzed 1074 patients with a history of cerebral infarction. The mean BP at baseline was 140.7/81.4 mmHg. Throughout the follow-up period, the mean BP was 133.4/77.5 (95% CI, 132.7–134.1/76.9–78.2) mmHg in the standard group and 126.7/74.1 (95% CI, 126.0–127.4/73.5–74.8) mmHg in the intensive group. During a mean follow-up of 3.9 years, 78 first recurrent strokes occurred. Intensive treatment tended to reduce overall annual stroke recurrence (1.74% in intensive vs. 2.17% in standard; P = 0.351 by log-rank test) and did not change the risk of ischemic stroke (1.74% vs. 1.75%, P = 0.999) but markedly reduced the risk of hemorrhagic stroke (0.00% vs. 0.39%, P = 0.005). Beneficial effects of intensive BP control were observed for the risk of hemorrhagic stroke in patients with a history of ischemic stroke. The findings of this study indicate the benefit of intensive BP control for patients with a history of ischemic stroke at high risk of hemorrhagic stroke. A total of 1074 patients with a history of ischemic stroke enrolled in The Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study were assigned to intensive blood pressure (BP) control group (blood pressure < 120/80 mmHg) or standard blood pressure control group (blood pressure < 140/90 mmHg) and were followed up for a mean of 3.9 years. Seventy-eight first recurrent strokes occurred, including 70 ischemic stroke and 8 intracerebral hemorrhage. Intensive treatment did not change annual risk of ischemic stroke (1.74% vs. 1.75%, P = 0.999), but markedly reduced risk of hemorrhagic stroke (0.00% vs. 0.39%, P = 0.005). Beneficial effect of intensive BP control were observed for risk of hemorrhagic stroke in the patients with a history of ischemic stroke.
Pineal region tumors pose certain challenges in regard to their resection: a deep surgical field,... more Pineal region tumors pose certain challenges in regard to their resection: a deep surgical field, associated critical surrounding neurovascular structures, and narrow operative working corridor due to obstruction by the apex of the culmen. The authors describe a lateral supracerebellar infratentorial approach that was successfully used in the treatment of 10 large (> 3 cm) midline pineal region tumors. The patients were placed in a modified lateral decubitus position. A small lateral suboccipital craniotomy exposed the transverse sinus. Tentorial retraction sutures were used to gently rotate and elevate the transverse sinus to expand the lateral supracerebellar operative corridor. This approach placed only unilateral normal structures at risk and minimized vermian venous sacrifice. The surgeon achieved generous exposure of the caudal midline mesencephalon through a "cross-court" oblique trajectory, while avoiding excessive retraction on the culmen. All patients underwent the lateral approach with no approach-related complication. The final pathological diagnoses were consistent with meningioma in 3 cases, pilocytic astrocytoma in 3 cases, intermediate grade pineal region tumor in 2 cases, and pineoblastoma in 2 cases. The entire extent of these tumors was readily reachable through the lateral supracerebellar route. Gross-total resection was achieved in 8 (80%) of the 10 cases; in 2 cases (20%) near-total resection was performed due to adherence of these tumors to deep diencephalic veins. Large midline pineal region tumors can be removed through a unilateral paramedian suboccipital craniotomy. This approach is simple, may spare some of the midline vermian bridging veins, and may be potentially less invasive and more efficient.
Few treatments exist for acute attacks of trigeminal neuralgia. Therefore, this study aimed to in... more Few treatments exist for acute attacks of trigeminal neuralgia. Therefore, this study aimed to investigate the efficacy and safety of an intravenous fosphenytoin therapy protocol in a trigeminal neuralgia crisis. We conducted a single-center, retrospective, observational study of the records of 20 patients with trigeminal neuralgia who received intravenous fosphenytoin therapy (15 mg/mL in normal saline at 50 mg/min for 15 min, total 750 mg) during hospitalization between September 2015 and August 2020. Serum phenytoin concentration was measured 30 min post-infusion. Pain severity was evaluated using a numerical rating scale and was analyzed for statistical significance. The mean age of the patients was 67.5 years (female, 50.0%). The median numerical rating scale score (interquartile range) of pain severity was 2.35 (0-10), 0.65 (0-5), 0.15 (0-1), 2.00 (0-8), and 4.30 (0-10) at 15, 30, and 60 min, and 12 and 24 h, respectively (p < .001); the numerical rating scale score was 10 before treatment. Reduction in pain 24 h following treatment was significant. The mean phenytoin concentration was 12.8 μg/mL 30 min post-treatment. While mild dizziness occurred in four patients, all could walk independently within 60 min. The mean age and weight of patients with mild dizziness were significantly higher and lower, respectively (p < .001), than those of other patients. These results may provide physicians with new insights into the innovative therapeutic option of intravenous fosphenytoin and contribute to advancements in treating acute trigeminal neuralgia crisis.
Hemifacial spasm (HFS) patients occasionally present with preoperative facial weakness (PFW) or d... more Hemifacial spasm (HFS) patients occasionally present with preoperative facial weakness (PFW) or develop delayed facial palsy (DFP) after microvascular decompression (MVD). This study is aimed to evaluate the neurophysiology underlying facial nerve motor dysfunction in HFS patients preoperatively and postoperatively. In all, 54 HFS patients without prior botulinum toxin injection who underwent MVD were retrospectively reviewed. The compound muscle action potential (CMAP) amplitude ratios of the affected and unaffected facial nerves, measured at 4 time points from preoperation to 1 year post-surgery, were aggregated. Clinical outcomes and the CMAP amplitude ratios were evaluated. Six patients (11.1%) presented with PFW, which correlated with advanced age (p = 0.007) and symptom duration (p = 0.001). The average duration to achieve PFW relief was 2.67 months postoperatively. The preoperative CMAP amplitude ratios of PFW patients were lower than those of patients without PFW (85.3% vs 95.7%). The ratios showed the lowest value at 1-week post-surgery in both groups (70.3% vs 90.9%), had a tendency toward improvement at 1 month, and finally recovered to almost the same level as that before the surgery at 1 year. Three patients (5.6%), whose CMAP ratios showed a persistent decrease from 1 week (56.5%) to 1 month (31%) after MVD, developed DFP. This study illustrates PFW in HFS patients reflects facial nerve axonal stress. MVD is effective in resolving spasm and PFW, without longterm damage to the facial nerve in most patients. In DFP patients, the direct and subsequent secondary axonal disorder develops on the postoperative facial nerve.
A 37-year-old female with myoma and adenomyosis of the uterus was treated with leuprorelin acetat... more A 37-year-old female with myoma and adenomyosis of the uterus was treated with leuprorelin acetate at 4-week intervals for a total of 6 times. During breakfast 12 weeks after the final administration, a tingling sensation in the right mouth angle and right thumb suddenly developed. Since the symptoms did not improve, she visited the neurosurgical department of our hospital. Brain MRI (DWI) showed a high signal intensity area (maximum diameter, 8 mm) in the left thalamus. Since the lesion diameter was ≤15 mm on images, and cheiro-oral syndrome was observed, a diagnosis of lacunar infraction was made. However, there were no risk factorsother than smoking. The infarction was a juvenile cerebral infarction without severe stenosis of the responsible blood vessel. Valvular heart disease, or atrial fibrillation can be sources of an embolism. Therefore, evaluation for possible paradoxical brain embolism was necessary. Close examination showed a patent foramen ovale and deep vein thrombosis accompanied by a right-left shunt. Concerning the cause of juvenile deep vein thrombosis, there were neither abnormalities in the coagulationfibrinolysis system nor autoimmune disease, and the involvement of leuprorelin acetate was strongly suggested. As for the adverse effects of this drug, thromboembolism is known, yet there have been no reports of paradoxical brain embolisms in Japan, Therefore, this case may be of valuable.
The authors regret in the original article, there were some mistakes in Table 4 as published. The... more The authors regret in the original article, there were some mistakes in Table 4 as published. The materials used at redo operation and numbers were placed incorrectly. The materials used at redo operation should be in the second column and the number should be in the third column. The corrected Table 4 appears below.
To investigate the characteristics of materials used as prostheses for microvascular decompressio... more To investigate the characteristics of materials used as prostheses for microvascular decompression surgery (MVDs) in Japan and their possible adverse events (AEs) to determine preferable materials for MVDs.-METHODS: A questionnaire was sent to all members of the Japanese Society for MVDs, and answers were obtained from 59 institutions.-RESULTS: Among a total of 2789 MVDs, 1088 operations for trigeminal neuralgia, 1670 for hemifacial spasm, and 31 others, including 117 reoperations, were performed between April 2011 and March 2014. Nonabsorbable material was used in 96.5% of MVDs, including polytetrafluoroethylene (PTFE) (80.5%), polyurethane (11.9%), expanded PTFE (2.1%), and silk thread (1.47%). The use of absorbable materials, including fibrin glue (87.5%), cellulose (13.5%), gelatin (4,77%), and collagen (1.76%), was reported. The major combinations were PTFE with fibrin glue (58.7%) followed by PTFE alone (7.60%). Eighty-eight AEs in 85 (3.2%) cases were reported among 2672 first operations. AEs included 51 central nervous system dysfunctions, 15 wound infections/dehiscence, and 10 others, which were presumed to be related to the intraoperative procedure. Among relatively high-, moderate-, and low-volume centers, there were no significant differences in the frequency of AEs (P [ 0.077). Tissue-prosthesis adhesion and/or granuloma formation were reported in 13 cases of 117 reoperations. The incidence of adhesion-related recurrence was 11.1% of all reoperations.-CONCLUSIONS: The number of AEs was quite low in this survey, and intradural use of any prosthesis reported in this paper might be justified; however, further development of easily handled and less-adhesive prosthesis materials is awaited.
BACKGROUND: Although the combined petrosal approach has significant advantages for medium to larg... more BACKGROUND: Although the combined petrosal approach has significant advantages for medium to large petroclival lesions, it carries the risk of a few major complications. The cerebrospinal fluid leak rate with this approach has been reported to be as high as 15%. OBJECTIVE: To describe an innovative technique of watertight dural closure with a long microplate-bridge technique for the combined petrosal approach. METHODS: We describe our method of watertight dural closures with the microplate-bridge technique for combined petrosal approaches using cadaveric heads and clinical cases. We review our postoperative outcomes in respect to cerebrospinal fluid leaks. RESULTS: The technique involves a fascial graft to the presigmoid-subtemporal defect, fixated with a long microtitanium plate over the cranial base side. The fascial graft is augmented by covering it with an abdominal fat graft and a vascularized pericranial flap. This technique was performed in 23 patients after surgical resectio...
Trigeminal neuralgia (TN) caused by the primitive trigeminal artery (PTA) and PTA variants is ver... more Trigeminal neuralgia (TN) caused by the primitive trigeminal artery (PTA) and PTA variants is very unusual, accounting for 0.2-0.6％ of TN cases, particularly the intermediate PTA type which is extremely rare and has only been reported twice in previous studies. We describe a case of TN caused by an anomalous artery originating directly from the PTA. A 68-year-old woman with a 4-year history of TN in the right V2 distribution visited our hospital. The patient's pain was poorly controlled with oral medicine. The 3D MRI/MRA fusion and MR constructive interference in steady state(CISS)images revealed an abnormal artery branching from the PTA compressing the trigeminal nerve in the cerebellopontine angle. During microvascular decompression (MVD) , the offending artery was transposed at two points on the trigeminal nerve, the root entry zone, and the cisternal portion. The patient's TN improved immediately after surgery. The patient's postoperative course was uneventful. Both, 3T MRI/MRA 3D fusion and CISS images were useful in identifying the anatomical relationship between the PTA and the trigeminal nerve, thus, allowing the optimal operative strategy.
Although microvascular decompression (MVD) is a reliable treatment for trigeminal neuralgia (TN),... more Although microvascular decompression (MVD) is a reliable treatment for trigeminal neuralgia (TN), neurosurgeons sometimes encounter patients whose symptoms do not improve postoperatively or who experience good treatment efficacy but develop other sensory disturbances. This study aims to objectively identify changes in nerve fibers before and after surgery by MRI and to clarify the relationship between the changes and residual postoperative symptoms. We retrospectively analyzed data from 36 consecutive patients who underwent MVD for classical TN at our hospital between November 2019 and November 2020. Cases that fulfilled the diagnostic criteria for multiple sclerosis were excluded. We confirmed the changes on the brainstem side of the trigeminal nerve preoperatively and at seven days postoperatively using 3D T2-SPACE MRI, in which the patients were divided into three groups: preoperative T2 high intensity positive (A), postoperative T2 high intensity positive (B), and no T2 highintensity region (C). The primary outcome measures were therapeutic efficacy and frequency of postoperative numbness. The results of MVD surgery were evaluated one year postoperatively. The percentage of cases in which treatment outcomes were rated as excellent or good at one year: group A: 0 (0%), group B: 6 (100%), and group C: 25 (96.2%) (p < 0.05); the frequency of numbness: 2 (50%) in group A, 3 (50%) in group B, and 1 (3.8%) in group C, indicating significant differences between the three groups (p < 0.05). 3D T2-SPACE MRI sequences can be used to identify changes in trigeminal nerve fibers before and after MVD, which might correlate with eventual residual symptoms.
Neck clipping of large internal carotid-posterior communicating artery (IC-PC) aneurysms is gener... more Neck clipping of large internal carotid-posterior communicating artery (IC-PC) aneurysms is generally difficult, especially when the anterior choroidal artery adheres to the aneurysm. We report 2 cases with premature rupture during the dissection of the anterior choroidal artery adhering to aneurysmal dome. The rupture point was not from the dissecting area, but from the medial wall of the aneurysmal dome, which also adhered to optic nerve. The traction force seemed
Although microvascular decompression (MVD) is a reliable treatment for hemifacial spasm (HFS), po... more Although microvascular decompression (MVD) is a reliable treatment for hemifacial spasm (HFS), postoperative delayed relief of persistent HFS is one of the main issues. In patients with hemifacial spasm, stimulation of a branch of the affected facial nerve elicits an abnormal response in the muscles innervated by another branch. Several specific types of waves were found in the abnormal muscle response (AMR). This study aimed to confirm the relationship between the initial morphology of the AMR wave and delayed relief of persistent HFS after MVD. We retrospectively analyzed and compared the data from 47 of 155 consecutive patients who underwent MVD for HFS at our hospital between January 2015 and March 2020. Based on the pattern of the initial AMR morphology on orbicularis oculi and mentalis muscle stimulation, patients were divided into two groups, namely, the monophasic and polyphasic groups. The results of MVD surgery for HFS were evaluated 1 week, 1 month, and 1 year postoperatively, by evaluating whether or not the symptoms of HFS persisted at the time of each follow-up. There were significantly higher rates of persistent postoperative HFS in patients with the polyphasic type of initial AMR at 1 week and 1 month after the surgery (p < 0.05, respectively), as assessed using Yates chi-squared test and Fisher's exact test. A significant correlation was observed between delayed relief after MVD and polyphasic morphology of the AMR in electromyographic analysis in patients with hemifacial spasm.
The Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study and its pooled analysis showed t... more The Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study and its pooled analysis showed that intensive blood pressure (BP) lowering reduced recurrent stroke risk by 22% in patients with a history of stroke. Here, we report the effect of intensive BP lowering on the risk of recurrent stroke subtypes in patients with a history of ischemic stroke. RESPECT was a randomized clinical trial among 1280 people with a history of cerebral infarction or intracerebral hemorrhage. Participants were assigned to the intensive blood pressure control group (blood pressure < 120/80 mmHg) or standard blood pressure control group (blood pressure < 140/90 mmHg). In this post hoc analysis, we analyzed 1074 patients with a history of cerebral infarction. The mean BP at baseline was 140.7/81.4 mmHg. Throughout the follow-up period, the mean BP was 133.4/77.5 (95% CI, 132.7–134.1/76.9–78.2) mmHg in the standard group and 126.7/74.1 (95% CI, 126.0–127.4/73.5–74.8) mmHg in the intensive group. During a mean follow-up of 3.9 years, 78 first recurrent strokes occurred. Intensive treatment tended to reduce overall annual stroke recurrence (1.74% in intensive vs. 2.17% in standard; P = 0.351 by log-rank test) and did not change the risk of ischemic stroke (1.74% vs. 1.75%, P = 0.999) but markedly reduced the risk of hemorrhagic stroke (0.00% vs. 0.39%, P = 0.005). Beneficial effects of intensive BP control were observed for the risk of hemorrhagic stroke in patients with a history of ischemic stroke. The findings of this study indicate the benefit of intensive BP control for patients with a history of ischemic stroke at high risk of hemorrhagic stroke. A total of 1074 patients with a history of ischemic stroke enrolled in The Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study were assigned to intensive blood pressure (BP) control group (blood pressure < 120/80 mmHg) or standard blood pressure control group (blood pressure < 140/90 mmHg) and were followed up for a mean of 3.9 years. Seventy-eight first recurrent strokes occurred, including 70 ischemic stroke and 8 intracerebral hemorrhage. Intensive treatment did not change annual risk of ischemic stroke (1.74% vs. 1.75%, P = 0.999), but markedly reduced risk of hemorrhagic stroke (0.00% vs. 0.39%, P = 0.005). Beneficial effect of intensive BP control were observed for risk of hemorrhagic stroke in the patients with a history of ischemic stroke.
Pineal region tumors pose certain challenges in regard to their resection: a deep surgical field,... more Pineal region tumors pose certain challenges in regard to their resection: a deep surgical field, associated critical surrounding neurovascular structures, and narrow operative working corridor due to obstruction by the apex of the culmen. The authors describe a lateral supracerebellar infratentorial approach that was successfully used in the treatment of 10 large (> 3 cm) midline pineal region tumors. The patients were placed in a modified lateral decubitus position. A small lateral suboccipital craniotomy exposed the transverse sinus. Tentorial retraction sutures were used to gently rotate and elevate the transverse sinus to expand the lateral supracerebellar operative corridor. This approach placed only unilateral normal structures at risk and minimized vermian venous sacrifice. The surgeon achieved generous exposure of the caudal midline mesencephalon through a "cross-court" oblique trajectory, while avoiding excessive retraction on the culmen. All patients underwent the lateral approach with no approach-related complication. The final pathological diagnoses were consistent with meningioma in 3 cases, pilocytic astrocytoma in 3 cases, intermediate grade pineal region tumor in 2 cases, and pineoblastoma in 2 cases. The entire extent of these tumors was readily reachable through the lateral supracerebellar route. Gross-total resection was achieved in 8 (80%) of the 10 cases; in 2 cases (20%) near-total resection was performed due to adherence of these tumors to deep diencephalic veins. Large midline pineal region tumors can be removed through a unilateral paramedian suboccipital craniotomy. This approach is simple, may spare some of the midline vermian bridging veins, and may be potentially less invasive and more efficient.
Few treatments exist for acute attacks of trigeminal neuralgia. Therefore, this study aimed to in... more Few treatments exist for acute attacks of trigeminal neuralgia. Therefore, this study aimed to investigate the efficacy and safety of an intravenous fosphenytoin therapy protocol in a trigeminal neuralgia crisis. We conducted a single-center, retrospective, observational study of the records of 20 patients with trigeminal neuralgia who received intravenous fosphenytoin therapy (15 mg/mL in normal saline at 50 mg/min for 15 min, total 750 mg) during hospitalization between September 2015 and August 2020. Serum phenytoin concentration was measured 30 min post-infusion. Pain severity was evaluated using a numerical rating scale and was analyzed for statistical significance. The mean age of the patients was 67.5 years (female, 50.0%). The median numerical rating scale score (interquartile range) of pain severity was 2.35 (0-10), 0.65 (0-5), 0.15 (0-1), 2.00 (0-8), and 4.30 (0-10) at 15, 30, and 60 min, and 12 and 24 h, respectively (p < .001); the numerical rating scale score was 10 before treatment. Reduction in pain 24 h following treatment was significant. The mean phenytoin concentration was 12.8 μg/mL 30 min post-treatment. While mild dizziness occurred in four patients, all could walk independently within 60 min. The mean age and weight of patients with mild dizziness were significantly higher and lower, respectively (p < .001), than those of other patients. These results may provide physicians with new insights into the innovative therapeutic option of intravenous fosphenytoin and contribute to advancements in treating acute trigeminal neuralgia crisis.
Hemifacial spasm (HFS) patients occasionally present with preoperative facial weakness (PFW) or d... more Hemifacial spasm (HFS) patients occasionally present with preoperative facial weakness (PFW) or develop delayed facial palsy (DFP) after microvascular decompression (MVD). This study is aimed to evaluate the neurophysiology underlying facial nerve motor dysfunction in HFS patients preoperatively and postoperatively. In all, 54 HFS patients without prior botulinum toxin injection who underwent MVD were retrospectively reviewed. The compound muscle action potential (CMAP) amplitude ratios of the affected and unaffected facial nerves, measured at 4 time points from preoperation to 1 year post-surgery, were aggregated. Clinical outcomes and the CMAP amplitude ratios were evaluated. Six patients (11.1%) presented with PFW, which correlated with advanced age (p = 0.007) and symptom duration (p = 0.001). The average duration to achieve PFW relief was 2.67 months postoperatively. The preoperative CMAP amplitude ratios of PFW patients were lower than those of patients without PFW (85.3% vs 95.7%). The ratios showed the lowest value at 1-week post-surgery in both groups (70.3% vs 90.9%), had a tendency toward improvement at 1 month, and finally recovered to almost the same level as that before the surgery at 1 year. Three patients (5.6%), whose CMAP ratios showed a persistent decrease from 1 week (56.5%) to 1 month (31%) after MVD, developed DFP. This study illustrates PFW in HFS patients reflects facial nerve axonal stress. MVD is effective in resolving spasm and PFW, without longterm damage to the facial nerve in most patients. In DFP patients, the direct and subsequent secondary axonal disorder develops on the postoperative facial nerve.
A 37-year-old female with myoma and adenomyosis of the uterus was treated with leuprorelin acetat... more A 37-year-old female with myoma and adenomyosis of the uterus was treated with leuprorelin acetate at 4-week intervals for a total of 6 times. During breakfast 12 weeks after the final administration, a tingling sensation in the right mouth angle and right thumb suddenly developed. Since the symptoms did not improve, she visited the neurosurgical department of our hospital. Brain MRI (DWI) showed a high signal intensity area (maximum diameter, 8 mm) in the left thalamus. Since the lesion diameter was ≤15 mm on images, and cheiro-oral syndrome was observed, a diagnosis of lacunar infraction was made. However, there were no risk factorsother than smoking. The infarction was a juvenile cerebral infarction without severe stenosis of the responsible blood vessel. Valvular heart disease, or atrial fibrillation can be sources of an embolism. Therefore, evaluation for possible paradoxical brain embolism was necessary. Close examination showed a patent foramen ovale and deep vein thrombosis accompanied by a right-left shunt. Concerning the cause of juvenile deep vein thrombosis, there were neither abnormalities in the coagulationfibrinolysis system nor autoimmune disease, and the involvement of leuprorelin acetate was strongly suggested. As for the adverse effects of this drug, thromboembolism is known, yet there have been no reports of paradoxical brain embolisms in Japan, Therefore, this case may be of valuable.
The authors regret in the original article, there were some mistakes in Table 4 as published. The... more The authors regret in the original article, there were some mistakes in Table 4 as published. The materials used at redo operation and numbers were placed incorrectly. The materials used at redo operation should be in the second column and the number should be in the third column. The corrected Table 4 appears below.
To investigate the characteristics of materials used as prostheses for microvascular decompressio... more To investigate the characteristics of materials used as prostheses for microvascular decompression surgery (MVDs) in Japan and their possible adverse events (AEs) to determine preferable materials for MVDs.-METHODS: A questionnaire was sent to all members of the Japanese Society for MVDs, and answers were obtained from 59 institutions.-RESULTS: Among a total of 2789 MVDs, 1088 operations for trigeminal neuralgia, 1670 for hemifacial spasm, and 31 others, including 117 reoperations, were performed between April 2011 and March 2014. Nonabsorbable material was used in 96.5% of MVDs, including polytetrafluoroethylene (PTFE) (80.5%), polyurethane (11.9%), expanded PTFE (2.1%), and silk thread (1.47%). The use of absorbable materials, including fibrin glue (87.5%), cellulose (13.5%), gelatin (4,77%), and collagen (1.76%), was reported. The major combinations were PTFE with fibrin glue (58.7%) followed by PTFE alone (7.60%). Eighty-eight AEs in 85 (3.2%) cases were reported among 2672 first operations. AEs included 51 central nervous system dysfunctions, 15 wound infections/dehiscence, and 10 others, which were presumed to be related to the intraoperative procedure. Among relatively high-, moderate-, and low-volume centers, there were no significant differences in the frequency of AEs (P [ 0.077). Tissue-prosthesis adhesion and/or granuloma formation were reported in 13 cases of 117 reoperations. The incidence of adhesion-related recurrence was 11.1% of all reoperations.-CONCLUSIONS: The number of AEs was quite low in this survey, and intradural use of any prosthesis reported in this paper might be justified; however, further development of easily handled and less-adhesive prosthesis materials is awaited.
BACKGROUND: Although the combined petrosal approach has significant advantages for medium to larg... more BACKGROUND: Although the combined petrosal approach has significant advantages for medium to large petroclival lesions, it carries the risk of a few major complications. The cerebrospinal fluid leak rate with this approach has been reported to be as high as 15%. OBJECTIVE: To describe an innovative technique of watertight dural closure with a long microplate-bridge technique for the combined petrosal approach. METHODS: We describe our method of watertight dural closures with the microplate-bridge technique for combined petrosal approaches using cadaveric heads and clinical cases. We review our postoperative outcomes in respect to cerebrospinal fluid leaks. RESULTS: The technique involves a fascial graft to the presigmoid-subtemporal defect, fixated with a long microtitanium plate over the cranial base side. The fascial graft is augmented by covering it with an abdominal fat graft and a vascularized pericranial flap. This technique was performed in 23 patients after surgical resectio...
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